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In-depth: Surgery catch-up hamstrung by shortage of ICU nurses

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Hospitals in South Africa have been put under immense strain over the past two years as beds were filled with Covid-19 patients and elective surgeries had to be put on hold.

To make things worse, pre-existing shortages of intensive care trained nurses and other critical staff were exacerbated by healthcare workers themselves contracting SARS-CoV-2 and falling ill or having to isolate themselves. Below we explore surgery catch-up plans in Gauteng and the Western Cape and ask what is done to address the underlying problem of not having enough ICU nurses.

Catching up in the Western Cape

Mark van der Heever, spokesperson for the Western Cape Department of Health, says by mid-January they had 758 active cases of healthcare workers who tested positive for SARS-CoV-2.

“Although the numbers remain significantly high, staff are returning to work as they come out of isolation and there is an overall easing of pressure of the health platform.

"The Omicron wave did not have the impact on health services the way the first three waves had. For example, at Tygerberg Hospital we did not de-escalate our normal operations during the fourth wave,” he says.

Looking back, Yolanda Walsh, a registered nurse specialising in critical care, says the second and third waves were horrendous.

“You know, all hell was breaking loose. There was a triaging system and critical decisions had to be made on whether you continue giving a patient in the ICU more time or you give the one outside a chance. The workload was something else and remember ICU beds have always been a problem, even before Covid-19,” she tells Spotlight. “We were running up and down, the sweat was flowing down to the legs. It was quite traumatising,” she says.

Apart from the psychological trauma of those earlier waves, their impact is also felt in the ongoing backlog of elective surgeries.

“Nurses are not ok. We don’t have the numbers and we don’t have the quality for critical care,” says Walsh. “We are dealing with very tired, short-staffed nurses and they still have to go through thousands of surgeries. So many surgeries had to be postponed and re-postponed and this had a major impact on people.”

‘unlikely to ever catch up’

At Tygerberg Hospital 7 000 patients were waiting on surgeries by late January, and the head of the department of surgery, Professor Elmin Steyn says they “are unlikely to ever catch up”.

Acting spokesperson for Tygerberg Hospital Rozaun Botes, however, says they did not de-escalate their normal operations during the fourth wave, so waiting lists for emergency surgery were not out of the ordinary.

“We have 30 theatres all running at full capacity,” she says. “We normally de-escalate services between Christmas and New Year where we basically only focus on emergency operations. Last year, we had to bring it forward with one week and that was due to staff testing positive. Qualitatively and quantitatively the impact was not as severe as with the first three waves,” she says.

Botes says catching up is not easy “as over and above the normal activities we have to create more services to catch up and that is not easy as it requires more human resources and theatre time which costs money.”

She says they do not have a shortage of ICU nurses in general. “There is a shortage of trained ICU specialist nurses, but we appoint and train General Professional Nurses to support the staffing complement. During the pandemic, we appointed additional nurses on contract to support with the patient load,” says Botes.

Groote Schuur: Surgical recovery project

At Groote Schuur Hospital (GSH) Professor Lydia Cairncross, head of general surgery says like all other hospitals in the country, the pandemic had a significant impact.

“We had to prepare our hospital for the waves by decreasing out-patient clinic visits and all non-urgent clinical services. This included surgical procedures. For large parts of 2020 and 2021, our theatre ran at 50% of its normal capacity.

"This meant that while we were able to assist patients who required emergency operations, patients who were waiting for essential but not emergency surgery had to be postponed. During this time we did 10 000 fewer operations than in the 2018/2019 period.”

The hospital has over 6 000 patients, right now, waiting for surgery. The operations on this list include surgery for cataracts, joint replacements, hernia and gall bladder surgery, prostate surgery, and gynaecological operations.

“While we tried our best to keep our cancer surgery service running, these backlogs do affect cancer waiting time to a certain extent too. We are planning a one-year Surgical Recovery Project to decrease this backlog and waiting time for our patients.

"As the health system returns to relatively normal functioning, we are inundated with new patients into the system who also need our assistance and often surgery as part of that. With a system running at capacity, it is almost impossible to add on extra operating but that is what we need to do as Covid added an extra burden of disease to the system as a whole,” says Cairncross.

The idea of the Surgical Recovery Project is to run an additional 1 500 operations over one year as a theatre service parallel to their normal operation. There is a need for a core theatre team of nurses and anaesthetists and generalist surgeons to make this possible, hence they are fundraising for R15 million towards employing this team for a year. The Gift of the Givers has committed R5 million towards this project.

Cairncross notes that huge shortages in intensive care trained nursing were highlighted by the pandemic. “This shortage was the main factor affecting our ability to expand ICU, not the lack of the ventilator machines. It is the people to look after the patients that became the limiting factor.

"This lack of sufficiently trained intensive care nurses is not limited to Groote Schuur but is a provincial and national phenomenon. To provide a service, we needed to use locum staff and our own staff members were stretched to their limits, doing extra overtime to meet the massive increased need during Covid.

"During the peak of the third wave, Groote Schuur’s ICU expanded to three times its normal capacity to treat patients with Covid pneumonia,” she says.

Walsch says there is a need to acknowledge that there is a problem, invest, and create more posts to be able to deal with the shortage of intensive care nurses. “In South Africa, there is very little incentive for a critically qualified nurse and a registered nurse so there is no motivation really to train as a critical care nurse,” she says. “I don’t think there are nearly enough nurses especially for specialised care.”

Catching up in Gauteng

Kwara Kekana, spokesperson for the Gauteng Department of Health, says by June last year there were 700 ICU-trained nurses in their province. The ideal number is 1 421. This meant that the critical care trained nurse to patient ratio is 1:4, rather than the targeted 1:1.

“Many nurses went [into] isolation and quarantine and this exacerbated the shortage,” she says. According to Kekana, the province entered into agreements with two nursing agencies to supply nurses, employed nurses on Covid-19 contracts, and used its nursing staff overtime budget to deal with the shortages.

“Professional nurses were trained in a ten-day ICU short course to equip them with critical care skills,” she says.

Explaining the province’s training plans over the next three years, Kekana says the plan is to train 550 nurses in the 2022/23 financial year, 800 in 2023/24, and 800 in 2024/25. Professional nurses (general) will also be trained in Critical Care Nursing (Adult).

The plan is to train 76 by 2024, 90 by 2025, and 99 by 2026. She says the funding for this will come from the province’s budget for Health Sciences and Training.

Dr Nthabiseng Makgana, Acting CEO at the Pholosong Hospital in Brakpan, says the hospital is currently running six theatres during normal working hours and all departments are recalling patients and performing elective operations in order of priority to reduce the backlog. The hospital had elective surgical backlogs of 146 patients for general surgery, 67 for gynaecology, 91 for orthopaedics. The hospital had no backlogs for Ear, Nose, and Throat (ENT) and ophthalmology.

“Covid-19 contract personnel was injected to accommodate increased demand due to the pandemic, but there was a high need of highly specialised staff (ICU nurses, doctors, physiotherapists, etc.) to cater for critically ill Covid-19 patients. This was not always possible due to the limitation of scarce, highly specialised staff,” says Makgana.

Denosa: not enough specialist nurses

Sibongiseni Delihlazo , national spokesperson of the Democratic Nursing Organisation of South Africa (Denosa), also says the country does not have enough ICU-trained nurses. “In fact, we are very short of specialist nurses and pandemics like Covid-19 are seriously exposing this area. ICU nurses were burnt out and were not sure if they will be able to withstand the test of time post the second wave.

"They were drained physically, emotionally, and mentally with no intervention whatsoever from the government in terms of support in the form of time off due to the shortage,” he says.

Noting the nurse-to-patient ratios, he says in the ICU there must be one nurse per patient but the increase in admission to ICU of patients, especially due to Covid-19, is stretching this to a point where, in some instances, general nurses report that they are deployed into ICU without training.

“The situation is the same with maternity where general nurses would be allocated to delivery rooms without training. This is just how the shortage of staff and shortage of specialist nurses are compromising the quality of healthcare services,” he says.

Delihlazo believes government is not doing enough to train more specialised staff. “In fact, it is regressing terribly and South Africans should be concerned about that”. He says they lose many patients in facilities as a result of the shortage of staff. “Nurses are busy with critical patients and more patients get critical with no extra hand to look out for those.”

Cairncross also says not enough is being done to train more critical care nurses.

“From our perspective, this is a chronic problem which is not being adequately addressed at a systems level. The shortage is not only of intensive care trained nurses but, in fact, nurses in general. We need more nurse training colleges and to graduate more registered nurses, enrolled nurses, and enrolled nursing assistants for the country.

"We need to be training more specialised nurses at accredited institutions - across all disciplines - ICU and theatre are two major areas of shortfall,” she says.

Department of Health: Juggling budgets and staff shortages

National Department of Health spokesperson Foster Mohale says the department recruited additional staff and employed them on a temporary basis to cope with the demand for care in the management of Covid-19. He says staff was recruited through additional resources allocated to departments for Covid-19 (Covid-19 grant), recruiting and deployment of a foreign health workforce (Cuban Brigade), use of personnel recruited through nursing agencies by some provinces as a temporal stop-gap measure, and using community service staff.

“There was an implementation of an ICU short course for nurses (including non-ICU nurses) as a short-term measure to increase capacity for management of Covid-19 patients in the short-term.

"In the medium to long term, government will continue to grapple with staff shortages as a result of budget constraints that are public-sector wide amid competing priorities,” he says.

He says government’s Personal and Salary Administration System (Persal) by 31 December 2021 showed that there were 23 350 vacant posts for nurses in all categories. Mohale says plans to increase nurses’ numbers depend on the availability of funded posts in provinces and currently, “recruitment of staff in provinces is negatively affected by fiscal constraints”.

Toward the end of 2020, the Department of Health approved a Human Resources for Health (HRH) Strategy 2030 that is supposed to guide government’s efforts relating to the training and retention of healthcare workers.

Owing to anticipated human resources for health capacity and resource constraints, Mohale says, “It was deemed critical to understanding the cost of implementing the strategy and government’s capacity to fund it. In this regard, a costing study aimed at identifying and generating cost estimates for the proposals in the Strategic Plan was commissioned and is being finalised.”

*This article was published by Spotlight - health journalism in the public interest.

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